Memory dysfunction, psychomotor slowing, and decreased executive function predict mortality in patients with heart failure and low ejection fraction.

BACKGROUND: The purpose of this study was to evaluate whether dysfunction of specific cognitive abilities is a predictor of impending mortality in adults with systolic heart failure (HF). METHODS: A total of 166 stable outpatients with HF completed cognitive function evaluation in language, working memory, memory, visuospatial ability, psychomotor speed, and executive function using a neuropsychological test battery. Demographic and clinical variables, comorbidity, depressive symptoms, and health-related quality of life were also measured. Patients were followed for 12 months to determine all-cause mortality. RESULTS: There were 145 survivors and 21 deaths. In logistic regression analyses, significant predictors of mortality were lower left ventricular ejection fraction (LVEF) and poorer scores on measures of global congnitive function Mini-Mental State Examination [MMSE], working memory, memory, psychomotor speed, and executive function. Memory loss was the most predictive cognitive function variable (overall chi(2) = 17.97, df = 2, P < .001; Nagelkerke R(2) = 0.20). Gender was a significant covariate in 2 models, with men more likely to die. Age, comorbidity, depressive symptoms, and health-related quality of life were not significant predictors. In further analyses, significant predictors of mortality were lower systolic blood pressure and poorer global cognitive function, working memory, memory, psychomotor speed, and executive function, with memory being the most predictive. CONCLUSIONS: As hypothesized, lower LVEF and memory dysfunction predicted mortality. Poorer global cognitive score as determined by the MMSE, working memory, psychomotor speed, and executive function were also significant predictors. LVEF or systolic blood pressure had similar predictive values. Interventions are urgently needed to prevent and manage memory loss in HF.

Clinical assessment and rest and stress echocardiography for prediction of long-term prognosis in African Americans with known or suspected coronary artery disease.

BACKGROUND: There is limited information on noninvasive risk stratification of African Americans, a high-risk group for cardiovascular events. We investigated the value of clinical assessment and echocardiography for the prediction of a long-term prognosis in African Americans. METHODS: Dobutamine echocardiography was performed in 324 African Americans. Two-dimensional measurements were performed at rest, and rest and stress wall motion was assessed. A retrospective follow-up was conducted for cardiac events: myocardial infarction (MI) or cardiac death (CD). RESULTS: The mean age was 59 +/- 12 years, and 83% of patients had hypertension. The follow-up was obtained in 318 (98%) patients for a mean of 5.3 years. The events occurred in 107 (33%) subjects. The independent predictors of events were history of MI (P = 0.001, risk ratio [RR] 2.04), ischemia (P = 0.007, RR 1.97), fractional shortening (P = 0.033, RR 0.08), and left atrial (LA) dimension (P = 0.034, RR 1.39). An LA size of 3.6 cm and a fractional shortening of 0.30 were the best cutoff values for the prediction of events. Prior MI, ischemia, LA size >3.6 cm, and fractional shortening <0.30 were each considered independent risk predictors for events. The event rates were 13%, 21%, 38%, 59%, and 57% in patients with 0, 1, 2, 3, and 4 risk predictors, respectively. Event-free survival progressively worsened with an increasing number of predictors: 0 or 1 versus 2 predictors, P < 0.001; 2 versus 3 or 4 predictors, P = 0.003. CONCLUSION: The long-term prognosis of African Americans can be accurately predicted by clinical assessment combined with rest and stress echocardiography.

Pharmacist intervention to improve medication adherence in heart failure: a randomized trial.

BACKGROUND: Patients with heart failure who take several prescription medications sometimes have poor adherence to their treatment regimens. Few interventions designed to improve adherence to therapy have been rigorously tested. OBJECTIVE: To determine whether a pharmacist intervention improves medication adherence and health outcomes compared with usual care for low-income patients with heart failure. DESIGN: Randomized, controlled trial conducted from February 2001 to June 2004. SETTING: University-affiliated, inner-city, ambulatory care practice. PATIENTS: 314 low-income patients 50 years of age or older with heart failure confirmed by their primary care physician. INTERVENTION: Patients were randomly assigned to intervention (39% [n = 122]) or usual care (61% [n = 192]) groups and were followed for 12 months. A pharmacist provided a 9-month multilevel intervention, with a 3-month poststudy phase. An interdisciplinary team of investigators designed the intervention to support medication management by patients who have low health literacy and limited resources. MEASUREMENTS: Primary outcomes were adherence, as measured by using electronic prescription monitors, and exacerbations requiring emergency department care or hospital admission. Secondary outcomes included health-related quality of life, patient satisfaction with pharmacy services, and total direct costs. RESULTS: During the 9-month intervention period, medication adherence was 67.9% and 78.8% in the usual care and intervention groups, respectively (difference, 10.9 percentage points [95% CI, 5.0 to 16.7 percentage points]). However, these salutary effects dissipated in the 3-month postintervention follow-up period, in which adherence was 66.7% and 70.6%, respectively (difference, 3.9 percentage points [CI, -5.9 to 6.5 percentage points]). Medications were taken on schedule 47.2% of the time in the usual care group and 53.1% of the time in the intervention group (difference, 5.9 percentage points [CI, 0.4 to 11.5 percentage points]), but this effect also dissipated at the end of the intervention (48.9% vs. 48.6%, respectively; difference, 0.3 percentage point [CI, -5.9 to 6.5 percentage points]). Emergency department visits and hospital admissions were 19.4% less (incidence rate ratio, 0.82 [CI, 0.73 to 0.93]) and annual direct health care costs were lower ($-2960 [CI, $-7603 to $1338]) in the intervention group. LIMITATIONS: Because electronic monitors were used to ascertain adherence, patients were not permitted to use medication container adherence aids. The intervention involved 1 pharmacist and a single study site that served a large, indigent, inner-city population of patients. Because the intervention had several components, intervention effects could not be attributed to a single component. CONCLUSIONS: A pharmacist intervention for outpatients with heart failure can improve adherence to cardiovascular medications and decrease health care use and costs, but the benefit probably requires constant intervention because the effect dissipates when the intervention ceases. ClinicalTrials.gov registration number: NCT00388622.

Patient perception and provider assessment of severity of heart failure as predictors of hospitalization.

OBJECTIVE: To assess the agreement between 2 methods of assigning New York Heart Association (NYHA) functional class to patients with chronic heart failure (CHF): deriving NYHA class from self-report interview data versus clinician assignment. To then determine the ability of each method to predict all-cause hospitalization. METHODS: Adults with CHF > or = 50 years old from an urban health system in Indianapolis, Indiana, were administered the Kansas City Cardiomyopathy Questionnaire (a validated CHF symptom questionnaire) at baseline. Patient self-reported functional data were then used to derive NYHA class. Clinical providers who were blinded to patients' questionnaire data independently assessed NYHA functional class. We used a weighted kappa statistic to evaluate the agreement between the NYHA class from patient-derived and that from provider-assigned methods. We then assessed the ability of patient and provider NYHA to predict time to hospitalization using Cox proportional hazards models. RESULTS: Of 156 patients with complete 6-month follow-up (mean age 63 years +/- 9 SD, 53% African American, and 68% women), the correlation coefficient was 0.43 between the patient-derived and provider-assigned NYHA methods. The weighted kappa statistic was 0.278, and the 95% confidence interval was 0.18 to 0.37, indicating only slight agreement. Patients classified themselves in worse categories than did their providers. Provider-assigned NYHA was a better predictor of hospitalization (P = .06). CONCLUSIONS: There is only slight agreement between patient-derived and clinician-assigned NYHA functional class. A different approach with patients may be needed if providers hope to use patients' reports to identify those at risk for hospitalization.

Health care and medication costs and use among older adults with heart failure.

BACKGROUND: Heart failure disproportionately affects older adults for whom multiple medications are prescribed to prevent exacerbations and hospitalization. To target interventions effectively, it is important to understand the association of medication acquisition with health care utilization and costs. METHODS: We used electronic medical records from an urban public health care system to identify patients aged >/=50 years who had a diagnosis of heart failure. We assessed the association between inappropriate or appropriate medication supplies and hospitalization and costs using multivariable analyses that adjusted for demographic characteristics, prior health care use, health status, and insurance status. RESULTS: Total health care costs for treating 1554 patients with heart failure from 1996 to 2000 were 36.6 million dollars (in 2000 dollars). Less than a third of patients received appropriate medication supplies (between 90% and 110% of the supplies needed) annually. Compared with patients with appropriate supplies, the odds of hospitalization were greater among those with undersupplies (odds ratio [OR] = 3.1; 95% confidence interval [CI]: 2.3 to 4.2; P <0.0001) or oversupplies (OR = 2.0; 95% CI: 1.7 to 2.4; P <0.0001). Total costs were 25% higher for patients with undersupplies (95% CI: 8% to 46%; P = 0.004) and 18% higher for those with oversupplies (95% CI: 7% to 30%; P = 0.0009) than for those with appropriate supplies. CONCLUSION: Among adults with heart failure, inappropriate medication supplies were associated with increased hospitalization and higher costs. Monitoring medication supplies from electronic medical records may be a useful component of programs aiming to improve care while managing costs.